The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as: A. Anisocoria B. Ataxia C. Cataract D. Diplopia Correct Answer: A. Anisocoria Unequal pupils are called anisocoria. Anisocoria,… Read More »
The nurse will need to assess the client’s performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion? A. Ileal conduit B. Kock pouch C. Neobladder D. Vesicostomy Correct Answer: B. Kock pouch The ileal conduit and vesicostomy are incontinent urinary diversions, and… Read More »
Which of the following patients is at greater risk for contracting an infection? A. A postoperative patient who has undergone orthopedic surgery. B. A patient receiving broad-spectrum antibiotics. C. A patient with leukopenia. D. A newly diagnosed diabetic patient. Correct Answer: C. A patient with leukopenia. Leukopenia… Read More »
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic? A. Administer insulin. B. Administer oxygen. C. Feed the infant glucose water (10%). D. Place the infant in a warmer. Correct Answer:… Read More »
Newly hired nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves? A. Breast B. Integumentary C. Ophthalmic D. Oral Correct Answer: D. Oral Gloves should be worn anytime there is a risk of… Read More »
The nurse is handling a client with chronic pancreatitis. Upon reviewing the client’s record, which of the following serum amylase levels is to be expected? A. 50 units/L. B. 150 units/L. C. 350 units/L. D. 650 units/L. Correct Answer: C. 350 units/L. The normal serum amylase level… Read More »
When providing care to clients with varied cultural backgrounds, it is imperative for the nurse to recognize that: A. Cultural considerations must be put aside if basic needs are in jeopardy. B. Generalizations about the behavior of a particular group may be inaccurate. C. Current health standards should determine the acceptability of… Read More »
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? A. A palpable radial pulse B. A palpable ulnar pulse C. Cool, pale fingers D. Pink nail beds Correct Answer: C. Cool, pale fingers A safety device on the wrist may… Read More »
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that: A. He may have a low threshold for pain. B. He was faking pain. C. Someone else gave… Read More »
Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods. B. Bladder training: delay voiding according to a pre-schedule timetable. C. Crede’s maneuver: apply gentle manual pressure to the lower abdomen. D. Kegel exercises: contract the pelvic muscles.… Read More »